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This is a presentation that was given at the Lost in Translation 2013: Exploring the Origins of Addiction conference, that took place on March 25 - 26, 2013 in Vancouver, British Columbia, Canada
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Impulsivity, Attention Deficits and Addiction: Perspectives on Concepts,
Diagnoses, and Treatment
Christian G. Schütz MD PhD MPH Associate Professor Institute of Mental Health, Dep. of Psychiatry Email: [email protected] Medical Manager The Burnaby Centre for Mental Health & Addiction
CGS
Overview • introduction and context • etiological considerations • attention deficits and impulsivity • interventions considerations • summary
CGS
Overview • introduction and context • etiological considerations • attention deficits and impulsivity • interventions considerations • summary
The Four Quadrant Framework for Co-Occurring Disorders
Less severe mental disorder/
less severe substance
abuse disorder
More severe mental disorder/
less severe substance
abuse disorder
More severe mental disorder/
more severe substance
abuse disorder
Less severe mental disorder/
more severe substance
abuse disorder
High severity
Mood disorders
Psychosis
Addiction
Anxiety disorders
Adult ADHD Self-Report Scale
ADHD screener >50%
18 questions Adler et al.
CGS
CGS
Overview • introduction and context • etiological considerations • attention deficits and impulsivity • interventions considerations • summary
genes environment
CGS www.thelancet.com Published online February 28, 2013
CGS www.thelancet.com Published online February 28, 2013
CGS
CGS www.thelancet.com Published online February 28, 2013
Consistent with a pleiotropic role of CACNA1C variants , neuro-imaging studies have documented effects of voltage gated calcium channels on a range of structural and functional brain phenotypes, including circuitry involved in: • emotion processing, • executive function, • attention, and • memory.
genes environment
CGS
Childhood predictors of adult ADHD: Results from the WHO World Mental Health (WMH) Survey Initiative Lara et al. An average of 50% of children with ADHD continued to meet DSM-IV criteria for ADHD as adults. Persistence was strongly related to: • attentional plus hyperactive type, • symptom severity, • comorbid major depressive disorder, • high comorbidity, • paternal anxiety-mood disorder • parental antisocial personality disorder. Childhood adversity predicted ADHD, but not persistence into adulthood
Lifetime trauma experience
Stahl Essential Psychopharmacology
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Stahl Essential Psychopharmacology
ADHD Addiction Bipolar Schizophrenia
SJ Lupien, BS McEwen, MR. Gunnar and C Heim. Nature Reviews Neuroscience 10, 434-‐445 (2009) adapted
SJ Lupien, BS McEwen, MR. Gunnar and C Heim. Nature Reviews Neuroscience 10, 434-‐445 (2009) adapted
BL Thompson, P Levitt & GD Stanwood Nature Reviews Neuroscience 10, 303-‐312 (April 2009)
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Substance use disorder
SJ Lupien, BS McEwen, MR. Gunnar and C Heim. Nature Reviews Neuroscience 10, 434-‐445 (2009) adapted
• The prefrontal cortex subserves conscious decision making (thoughtful reflective response).
• PFC is the brain region most sensitive to detrimental effects of stress exposure.
• Even mild acute uncontrollable stress can cause a dramatic loss of cognitive abilities
• Prolonged stress exposure causes architectural changes in prefrontal dendrites
AFT Arnstein Nature Reviews Neuroscience 10, 410-‐422 (June 2009)
genes
Multi-causality and Pleiotropy is the standard
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Overview • introduction and context • etiological considerations • impulsivity and attention deficits • interventions considerations • summary
CGS
Questionnaire Behavioral Tests
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Barratt Impulsivity Scale-11 (BIS) Patton et al., 1995 • motor impulsivity • non-planning • attentional impulsivity 30 items, likert scale
CGS
UPPS-P Impulsive Behavior Scale Perales et al. 2009 • lack of premeditation • lack of perseverance • “negative” urgency • "positive” urgency • sensation-seeking
59-item likert scale
CGS
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)
CGS
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)
CGS
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)
CGS Tüscher et al 2012
fronto-parietal–pre-motor circuits
prefrontal–striatal
CGS
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)
CGS
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)
CGS
Latent Discounting
Peters 2011
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UPPS+P
BIS
Total
Neg Urgency
(lack of) Premed
(lack of) Preserve
Sens Seeking
Pos Urgency
Total
A>en?on
Motor
Non-‐Planning
DERS Total
Acceptance Goals
Impulse Awareness
Strategy Clarity
.57* .11 .58* .54* .69** .37 .44
.66** .27 .63** .69** .47 .53* .47
.53* .28 .42 .17 .73*** .30 .48*
.52* .21 .36 .13 .70** .46 .64*
-.33 -.54* -.11 .15 -.01 -.52* -.41
.55* .23 .59* .55* .36 .45 .38
.15 .15 -.21 .01 .22 .09 .43
.12 .04 -.09 .13 .09 .06 .34
-.09 -.01 -.30 -.03 -.06 -.13 .08
.27 .28 - .41 -.02 .35 .23 .58*
DDT $100 $1000
.47 -.09
.24 -.22
.24 .08
.13 -.14
.37 -.10
.41 .03
-.33 -.17
-.30 -.17
-.28 -.07
-.35 -.21
SST -.34 -.06 -.21 -.26 -.32 -.20 .67** .48* .62** .65**
SWM -.64**
-.44
-.38
-.41
-.35
-.42
-.17 -.19 -.04
-.18
UPPS+P
BIS
Total
Neg Urgency
(lack of) Premed
(lack of) Preserve
Sens Seeking
Pos Urgency
Total
A>en?on
Motor
Non-‐Planning
DERS Total
Acceptance Goals
Impulse Awareness
Strategy Clarity
.57* .11 .58* .54* .69** .37 .44
.66** .27 .63** .69** .47 .53* .47
.53* .28 .42 .17 .73*** .30 .48*
.52* .21 .36 .13 .70** .46 .64*
-.33 -.54* -.11 .15 -.01 -.52* -.41
.55* .23 .59* .55* .36 .45 .38
.15 .15 -.21 .01 .22 .09 .43
.12 .04 -.09 .13 .09 .06 .34
-.09 -.01 -.30 -.03 -.06 -.13 .08
.27 .28 - .41 -.02 .35 .23 .58*
DDT $100 $1000
.47 -.09
.24 -.22
.24 .08
.13 -.14
.37 -.10
.41 .03
-.33 -.17
-.30 -.17
-.28 -.07
-.35 -.21
SST -.34 -.06 -.21 -.26 -.32 -.20 .67** .48* .62** .65**
SWM -.64**
-.44
-.38
-.41
-.35
-.42
-.17 -.19 -.04
-.18
Chao 2013 DERS: Difficulties in emotional regulaton scale DDT: Delayed Disounting SST Stop Signal Task SWM: Spatial working memory UPPS+P
CGS
REVIEW: Impulsivity as a determinant and consequence of drug use: a review of underlying processes Harriet De Wit (2008)
CGS
Subcomponents attention: Top down: Prefrontal Cortex: sustain, switch
divide inhibit distraction
Inferior temporal cortex: focus Posterior parietal association cortex: orienting
CGS
Overview • introduction and context • etiological considerations • attention deficits and impulsivity • interventions considerations • summary
CGS
CGS
Mood stabilizers have been used extensively to treat impulsive disorders. Moderate efficacy in at least half of patients studied have been reported. Results differ across specific mood stabilizers. Positive data have been published for Valproate, Phenytoin, Carbamazepine, Topiramate and Lithium. (not for Gabapentin and Levotireacetam). Some positive results for atypical neuroleptics (Olanzapine, Aripiprazole, Quetiapine) and antidepressant (Bupropion) have been reported. Based on ADHD treatment Stimulants (Modafinil, Methylphenidate, Amphetamine) Atomoxetine, have lead to positive results in some patients. Cognitive Behavior Therapies, Dialectical Behavior Therapy and Contingency Management seem to be more promising psychotherapeutic approaches.
Symptom-targeted strategies appear to provide the best likelihood of success when using medications to improve the care of patients with personality disorders. Impulsivity appears to be the most consistent fundamentally disturbed behavior linking the spectrum of bipolar conditions, including those that present more as personality disorders or aberrations of temperament. Mood stabilizers have been used extensively to treat impulsive and aggressive disorders. Although most studies have limitations in design, moderate efficacy in at least half of patients studied has been reported. Results differ across drugs. More positive data have been published for valproate, although most are from open-label trials. The role of impulsive drug seeking is a major component of persistent drug abuse. Currently, therapies are at best of modest utility. More systematic studies of drugs and of psychological strategies are needed to address cues that trigger impulsive drug seeking. Naturalistic long-term studies indicate high rates of prescriptions of mood stabilizers for patients with borderline personality disorders. Cognitive therapies to enhance adherence to medication treatments are promising, but surprisingly poorly studied in systematic trials
Symptom-targeted strategies appear to provide the best likelihood of success when using medications to improve the care of patients with personality disorders. Impulsivity appears to be the most consistent fundamentally disturbed behavior linking the spectrum of bipolar conditions, including those that present more as personality disorders or aberrations of temperament. Mood stabilizers have been used extensively to treat impulsive and aggressive disorders. Although most studies have limitations in design, moderate efficacy in at least half of patients studied has been reported. Results differ across drugs. More positive data have been published for valproate, although most are from open-label trials. The role of impulsive drug seeking is a major component of persistent drug abuse. Currently, therapies are at best of modest utility. More systematic studies of drugs and of psychological strategies are needed to address cues that trigger impulsive drug seeking. Naturalistic long-term studies indicate high rates of prescriptions of mood stabilizers for patients with borderline personality disorders. Cognitive therapies to enhance adherence to medication treatments are promising, but surprisingly poorly studied in systematic trials
Symptom-targeted strategies appear to provide the best likelihood of success when using medications to improve the care of patients with personality disorders. Impulsivity appears to be the most consistent fundamentally disturbed behavior linking the spectrum of bipolar conditions, including those that present more as personality disorders or aberrations of temperament. Mood stabilizers have been used extensively to treat impulsive and aggressive disorders. Although most studies have limitations in design, moderate efficacy in at least half of patients studied has been reported. Results differ across drugs. More positive data have been published for valproate, although most are from open-label trials. The role of impulsive drug seeking is a major component of persistent drug abuse. Currently, therapies are at best of modest utility. More systematic studies of drugs and of psychological strategies are needed to address cues that trigger impulsive drug seeking. Naturalistic long-term studies indicate high rates of prescriptions of mood stabilizers for patients with borderline personality disorders. Cognitive therapies to enhance adherence to medication treatments are promising, but surprisingly poorly studied in systematic trials
Bra
in (c
ell)
Glutamate GABA
Dopamine
Serotonin
Executive Control Reward/Motivation Emotional regulation
Beh
avio
r
Relapse Addiction Mood episode
Medication
Psychosocial setting Psychotherapy
Env
ironm
ent Abstract
Information
Incentives
Trust/threat signals
Bra
in
Executive Control Reward/Motivation Emotional regulation
Beh
avio
r ADH Addiction Mood episode
ECT, TMS, DBS..
Bra
in (a
nato
.)
DLPC OFPC Striatum VMPC Amygdala Insula
Executive Control Reward/Motivation Emotional regulation
Beh
avio
r
Relapse Addiction Mood episode
Psy
chot
hera
py
Bra
in
Executive Control Reward/Motivation Emotional regulation
Beh
avio
r
ADHD Addiction Mood episode
Mindfulness, Grounding
CM SCT, GNG
CBT, DBT, ME
CGS
SCT: Several researchers tried to improve trait self-control. Successful training generalized to other tasks. To this end, participants were asked to brush their teeth or use the computer mouse with the non-dominant hand, keep a good posture, avoid slang words, perform Stroop tasks, keep a financial diary, or adhere to study or exercise plans (Azor Hui et al., 2009; Gailliot, Plant, Butz, & Baumeister, 2007; Muraven, Baumeister, & Tice, 1999; Oaten & Cheng, 2006a, 2006b, 2007).
GNG: One program aimed at fostering response inhibition. In this study, participants completed an adapted Go/No-Go task. (Houben, Nederkoorn, Wiers, & Jansen, 2010)
• The prefrontal cortex subserves conscious decision making (thoughtful reflective response).
• PFC is the brain region most sensitive to detrimental effects of stress exposure.
• Even mild acute uncontrollable stress can cause a dramatic loss of cognitive abilities
• Prolonged stress exposure causes architectural changes in prefrontal dendrites
AFT Arnstein Nature Reviews Neuroscience 10, 410-‐422 (June 2009)
CGS
Overview • introduction and context • etiological considerations • attention deficits and impulsivity • interventions considerations • summary
CGS
Overview • introduction and context • etiological considerations • attention deficits and impulsivity • interventions considerations • summary
engagement in meaningful activities and relationships
self organization, structuring, healthy living
TREATMENT: diagnosis versus syndrome (domain-specific) informed
PSYCHO- SOCIAL SETTING
engagement in meaningful activities and relationships
self organization, structuring, healthy living
Contingency
Management
Cognitive
Behaviour
Avoidance
Training
PSYCHO- SOCIAL SETTING
SPECIFIC INTERVENTION
TREATMENT: diagnosis versus syndrome (domain-specific) informed
engagement in meaningful activities and relationships
self organization, structuring, healthy living
Contingency
Management
Cognitive
Behaviour
Avoidance
Training
Evidence based:
PSYCHO- SOCIAL SETTING
SPECIFIC INTERVENTION
Medication
Regular systematic off-label
CGS
Thank you for your attention